Hand and Wrist Osteoarthritis
Hand and wrist osteoarthritis (OA) is a common chronic joint disorder affecting one or more joints of the thumb, fingers or wrist. Symptoms may include pain, reduced grip strength, restricted range of motion (ROM) and stiffness, which can limit daily activities.
Symptomatic hand osteoarthritis has been reported in approximately 13–26% of some older study populations and is more common in women.¹ Evidence from rehabilitation research suggests that appropriately selected night splints, joint-protection education, assistive devices and home exercises may improve pain and function. Evidence for low-level laser therapy and lasting changes in stiffness is less consistent.¹
Clinically Relevant Anatomy
The hand and wrist contain 27 bones: eight carpal bones, five metacarpals and fourteen phalanges.
In osteoarthritis, articular cartilage undergoes progressive structural changes and may become thinner, accompanied by remodeling of the underlying bone. Healthy articular cartilage is specialized connective tissue that facilitates smooth joint movement.²
Epidemiology
Symptomatic hand osteoarthritis is particularly common in older adults and is reported more frequently in women. It is among the most prevalent musculoskeletal conditions affecting the hand.
The most commonly affected joints include the distal interphalangeal (DIP) joints, proximal interphalangeal (PIP) joints and the base of the thumb.
Symptomatic hand osteoarthritis can reduce grip strength and interfere with everyday activities.
Risk factors and associated features include: – Age: prevalence increases with age, particularly after the age of 55 in women.³ – Sex: disease is more common and may be more severe in women, especially after menopause.⁴ – Genetics: familial and genetic influences are relevant, although individual genetic associations remain uncertain. – Hand use and loading: mechanical factors may influence symptoms and affected joints. – People may not seek medical care despite significant symptoms.
A 2002 study reported symptomatic hand osteoarthritis in at least one joint in 13.2% of men and 26.2% of women aged over 70. Hand osteoarthritis was more common than knee osteoarthritis in that population.⁷
Pathophysiology
Hand osteoarthritis affects the entire synovial joint and involves an imbalance between tissue breakdown and repair processes.³
Research suggests that changes in subchondral bone contribute to the development and progression of osteoarthritis. Findings may include: – Subchondral bone thickening – Altered trabecular architecture – Osteophyte formation – Subchondral cysts.
These changes may accompany gradual cartilage loss, joint-space narrowing and subchondral sclerosis.³
Clinical Presentation
Common findings include:⁵ – Joint swelling – Stiffness, especially in the morning – Pain and stiffness in DIP and PIP joints, at the thumb base and sometimes at the metacarpophalangeal (MCP) joints – Reduced hand strength – Difficulty gripping or twisting objects, such as door handles – Heberden's nodes at DIP joints or Bouchard's nodes at PIP joints.
Diagnostic Assessment
Diagnosis may be challenging because several joints can be involved and symptoms and radiographic changes vary. The assessment combines clinical history and examination with imaging when appropriate. Laboratory tests are reserved mainly for considering alternative diagnoses.
Laboratory Tests
Blood tests such as rheumatoid factor (RF) and erythrocyte sedimentation rate (ESR) may help assess suspected inflammatory arthritis, but are not routinely needed to diagnose typical hand osteoarthritis.⁵
Imaging
Radiographs may demonstrate: – Joint-space narrowing – Osteophytes – Subchondral sclerosis, cysts or erosive changes.⁵ Kellgren–Lawrence grading is commonly used, although interpretation can vary between observers. Verbruggen and colleagues have proposed alternative systems for grading erosive and structural changes.⁶
MRI and other imaging techniques may be considered in selected cases, but their role in routine early assessment remains uncertain.⁵
Risk Factors
Factors associated with hand osteoarthritis include:⁵ – Female sex – Increasing age – Menopause – Family history – Higher body weight – Joint laxity – Previous hand injury – Occupational or recreational loading.
Clinical Classification Criteria
Altman and colleagues developed clinical classification criteria for hand osteoarthritis.⁹ They include hand pain, aching or stiffness together with findings such as hard-tissue enlargement in selected joints, fewer than three swollen MCP joints, hard-tissue enlargement in DIP joints, or deformity in specified hand joints. Classification criteria support consistent research definitions and do not replace clinical judgment.
Outcome Measures
Outcome measures can be used to monitor pain, disability and response to treatment.²,¹⁰ Examples include SACRAH (Score for Assessment and Quantification of Chronic Rheumatic Affections of the Hands), FIHOA (Functional Index for Osteoarthritis of the Hand), and DASH or QuickDASH.
Conservative Treatment
A systematic review of non-surgical interventions for hand osteoarthritis reported outcomes for several approaches.¹⁰
Intervention | Outcome | Evidence level |
Hand exercises | Improved grip strength, function and ROM; pain relief | Moderate |
Joint protection and assistive devices | Improved hand function and pain relief | Moderate |
Paraffin wax | Pain relief; improved ROM and function | Limited |
Low-temperature heat wraps | Pain relief and improved grip strength | Moderate |
CMC orthoses (splints) | Pain relief; improved function and grip strength | Moderate |
Pharmacological Treatment
No medication cures hand osteoarthritis. Pharmacological treatment aims to reduce pain and improve function, while balancing potential benefits with adverse effects.
Analgesics
Paracetamol (acetaminophen) may be considered for selected patients, although its effect on osteoarthritis pain is often small and safety should still be considered, especially with repeated high doses. Decisions should take account of other medications and individual risks.¹¹
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
NSAIDs, such as ibuprofen or naproxen, can relieve symptoms in some patients. Topical NSAIDs are often preferred for localized hand symptoms because they limit systemic exposure. Oral NSAIDs require particular consideration of gastrointestinal, cardiovascular and renal risks, especially with prolonged use.¹¹
Intra-articular Corticosteroid Injections
Corticosteroid injections may be considered in selected painful joints, particularly during inflammatory flares, but benefits are often temporary and evidence varies by joint and indication. Repeated injections require careful assessment of possible adverse effects.¹¹
Other Medications
Opioids are generally not recommended as routine treatment for hand osteoarthritis because of limited long-term benefit and risks including dependence and other adverse effects.¹¹
Disease-modifying and biological therapies are under investigation but are not established standard treatment for hand osteoarthritis.¹¹
Surgical Treatment
Surgery may be considered when severe pain and functional limitations persist despite appropriate conservative care. Pain relief is usually a principal goal, but some procedures reduce joint mobility. Expectations about postoperative function should be discussed carefully.¹¹
Indications
Considerations for surgery may include: – Persistent pain limiting daily activities – Insufficient improvement after adequate non-surgical management – Structural changes contributing to mechanical problems, such as marked deformity – Patient goals and an understanding of the trade-off between pain relief and mobility.¹¹
Common Procedures
Arthrodesis (joint fusion): – Can be performed in selected finger or wrist joints – Provides stability and often relieves pain but eliminates movement at the fused joint – May be suitable when stability and pain control are more important than preserving motion.¹¹
Arthroplasty (joint replacement): – May be considered for selected MCP, PIP or thumb-base joints – Aims to preserve some movement while reducing pain – Potential drawbacks include implant loosening, reduced strength, complications and limited implant durability.¹¹
Prognosis
Surgical outcomes vary by joint, procedure and patient. Arthrodesis often provides reliable pain relief at the cost of movement, whereas arthroplasty may preserve motion but can involve additional risks. Individual selection and informed discussion are essential.¹¹
Differential Diagnoses
Hand osteoarthritis can resemble other joint disorders. History, clinical examination and, when indicated, laboratory testing and imaging help distinguish alternative causes of symptoms.⁵
Psoriatic Arthritis
– May affect DIP joints or entire digits – Psoriasis plaques or nail changes may occur – Dactylitis ('sausage digits') can suggest inflammatory arthritis rather than typical osteoarthritis.
Rheumatoid Arthritis
– Frequently involves MCP, PIP and wrist joints – Often has a symmetrical pattern and prolonged morning stiffness or fatigue – Rheumatoid factor and anti-CCP antibodies may support the diagnosis in the appropriate clinical context.
Gout
– Can cause sudden, severe pain and swelling in a joint – Serum urate may be elevated but does not by itself establish the diagnosis – Tophaceous deposits and joint damage may occur in advanced disease.
Haemochromatosis
– Can affect MCP joints and wrists – Associated with iron overload – Other manifestations may include liver disease and diabetes.
Reactive Arthritis
– May follow gastrointestinal or genitourinary infections – Can include arthritis, urethritis or conjunctivitis – Often has an asymmetrical joint distribution.
References
Ye L, Kalichman L, Spittle A, Dobson F, Bennell K. Effects of rehabilitative interventions on pain, function and physical impairments in people with hand osteoarthritis: a systematic review. Arthritis research & therapy. 2011
Kaufmann RA, Logters TT, Verbruggen G, Windolf J, Goitz RJ. Osteoarthritis of the Distal Interphalangeal Joint. Journal of Hand Surgery. 2010; 35A: 2117-2125.
Goodman CC, Fuller KS. Pathology: implications for the physical therapist. Third Edition. St. Louis, MO: Saunders Elsevier; 2009.
Kalichman L, Hernández-Molina G. Hand osteoarthritis: an epidemiological perspective. Seminars in Arthritis and Rheumatism. 2010; 39:465-476.
Zhang W, Doherty M, Leeb BF, et al. EULAR evidence-based recommendations for the diagnosis of hand osteoarthritis: report of a task force of ESCISIT. Annals of Rheumatic Diseases. 2009; 68:8-17.
Feydy A, Pluot E, Guerini H, Drape JL. Role of imaging in spine, hand, and wrist osteoarthritis. 2009; 605-649.
Zhang Y, Niu J, Kelly-Hayes M, Chaisson CE, Aliabadi P, Felson DT. Prevalence of symptomatic hand osteoarthritis and its impact on functional status among the elderly: The Framingham Study. American journal of epidemiology. 2002 Dec 1;156(11):1021-7. :https://academic.oup.com/aje/article/156/11/1021/80530
Goldring SR. The role of bone in osteoarthritis pathogenesis. Rheumatic Disease Clinics of North America. 2008; 34: 561–571.
Altman, RD. Classification of disease: osteoarthritis. Seminars in Arthritis and Rheumatism. 1991; 20(6): 40-47.
Valdes K, Marik T. A systematic review of conservative interventions for osteoarthritis of the hand. Journal of Hand Therapy. 2010; 23: 334–351.
Talwalkar SC, Hayton MJ, Stanley JK. Wrist osteoarthritis. Scandinavian Journal of Surgery. 2008; 97: 305–309.
Walker MJ. Manual Physical Therapy Examination and Intervention of a Patient with Radial Wrist Pain: A Case Report. Journal of Orthopaedic and Sports Physical Therapy. 2004; 34 (12): 761-769.
